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Dear Director,
I have a new CEO who has decided he wants to replace our group, even though we’ve been here forever and have been very successful. Can he do this? Could we have prevented this?


Contracts are most at risk when one of two things occur—there is a major administrative change in the executive wing (CEO, COO, CNO) or there is an administrative change in the ED (chairman leaves). Given that the average life expectancy of a CEO or an ED chairman is about 5-7 years, there is plenty of opportunity to have your contract up for review or have your hospital put out an RFP (request for proposal).  No matter how long you’ve held your contract, unless you are a hospital employee, employed by the hospital to work in the ED, your contract can be at risk. Not only do we have to live with this thought, we ultimately have to live with a couple of other rules–the hospital president makes the rules of the house and since we live under his house, we have to live with his rules. If the hospital president wants to bring in a group he knows from another facility, there may be nothing you can do to prevent it. However, if you follow the information below, you might be able to explain why your group deserves to keep the job and if you prepare ahead of time, before the inevitable RFP, you can solidify a contract that can weather a change in leadership.

Get to Know the New Boss
Contracts are about performance and relationships. As soon as possible, once your hospital gets a new administrator that may impact your performance and contract stability, it’s your responsibility to get to know them and to understand their agenda. It’s also in this time period to begin outlining past performance and defining their future expectations. After all, your job is to make them look good. Keep in mind that the hospital president reports to the hospital board of directors so many of their actions or behaviors will be in response to pressures put on them by the board.

Although there are some unexplained decisions administrations make just to make a change to show authority, the overwhelming majority of the time, a group thinks they are “very successful” but they have not met the expectations of the hospital. Typically, it’s the repeated failure to meet expectations that results in lost contracts, not unfair decisions. These types of discussions need to occur prior to your administrator making a decision to change, not after the RFP has been put out.

Nursing Relationships
The relationships your physicians have with nursing staff are probably one of the most underrated yet most important when it comes to contract retention. The physicians and nurses can’t be seen by hospital administration as being in an “us” versus “them” mentality or it’s likely that hospital administration would need to replace one of the two sides. As I routinely tell my nurse manager, we’re in this together and our success or failure is linked, so we need to be on the same page. If you’re looking to improve your relationship with the nurses, (it starts with respect, courtesy, and teamwork) consider providing some education. This can vary from a 2 minute clinical vignette at the start of the day to a more formal presentation during a nurse staff meeting. Certainly if your department is working to improve issues such as sepsis care, a focused lecture on the resuscitation bundle with data from your department would be appropriate. If your department has several new nurses, consider assigning each of them a physician mentor—someone they can feel safe asking basic questions to and beginning to learn how physicians think and approach patients and what we expect and/or need from our nursing colleagues

Quality and Consistency
The ED and its providers must always provide “knock your socks off” performance. Since it’s hard to knock high quality care, flawless quality needs to be the standard. Given that core measures are an integral component of our report card, and soon will be part of how the hospital gets paid, achieving near perfection, if not perfection, needs to be the end result. Consistency needs to go hand in hand with quality. Although providers vary in quality, and to some extent individual skills, to the hospital and it’s private physician partners, the quality we provide needs to be consistent regardless of who our providers are, time of day, or day of week. Utilize analysis methods like Six Sigma to eliminate variance and if there are areas that need to be improved, be prepared to develop action plans.

Physician leaders (medical director and other senior physicians) should lead by example with high performance in productivity metrics and in communication with patients, staff, and referring physicians. The medical director should be sharing data with the group and using monthly staff meetings to develop the culture of the department. There should be specific targets developed (length of stay metrics, left without being seen, patient satisfaction, etc..) with individual physician accountability and action plans to achieve best practice metrics. The best EDs have staff whose actions are hard wired to achieve outstanding results.    

Integration with the medical staff
I knew of a contract that was being replaced by the CEO but was stopped when the medical staff rose up against the CEO to protect the current group. The CEO changed his decision and retained the current group even though this came with the financial penalty of breaking a new contract. Pretty amazing if you ask me and while getting this kind of response from the medical staff might not even guarantee success, having a strong and strong willed medical staff come to your rescue can push a CEO away from change. After all, the CEO can’t afford to alienate a large portion of the private practice medical staff. How do you get this kind of response? It goes beyond quality and consistent care. The physicians have to be part of the hospital community. This means being involved in all aspects of medical staff leadership—from MEC and medical staff president to consistent and regular attendance at committee meetings. And this just can’t be the department chairman. The more emergency physicians that are involved, the better. Every emergency physician in the group should have some role to play in the hospital community. One example would be to identify an emergency physician who can serve as liaisons to other departments. This could mean attending the other department’s meetings to be aware of issues that impact the ED.

I’ve written about committee work before in this column and its importance. Since then, I’ve come across more and more emergency physicians who sit on the hospital’s Board of Directors. In that position, they become part of the group that the hospital president reports to and it can become pretty tough for a hospital president to remove your group when you are in a position, as a board member, to remove him or her. Ultimately, it comes down to being a good citizen of the ED and also of the hospital—active and visible.

As mentioned above, changing ED physician leadership can be an opportunity for the hospital administration to think about reviewing the ED contract. Having a clear secession plan can help to prevent this. The best organizations have built in plans to insure successful leadership change without negatively impacting performance. If the ED staff, the medical staff, and the hospital administration can see a clear and obvious transition to a new leader, this potentially tumultuous time can be seen as a natural progression of events and leave the department unscathed.

Conclusion
In the best of circumstances, the ED leader and the hospital administration are stable, there are defined expectations which the ED meets, and the ED chairman meets regularly with the hospital president. All of these increase your contract stability.  But no matter how stable we think our contract is, complacency can’t set in, as there is always another group who would like to expand their portfolio and take over our group or there is an incident that is about to happen that could put the contract at risk. However, if your goals include maintaining exceptional performance, becoming an integral component of the medical community, and working collaboratively with your nursing team, you have a much better chance of contract retention.

Michael Silverman, MD, is a member of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center in Arlington, Virginia.

 

Comments   

# ReallyHDoc 2011-06-10 05:47
The real problem is, is that each new Administrator has to prove how much they "Improved things" during their time there. No one EVER wants to just leave things alone- that way they look like a "do nothing" administrator. Frequently, Administrators are barraged by different ER groups promising to staff the ER better and cheaper, so Administrators believe they will improve things by switching groups.
Thats the reality of it.
Reply
# EDL 2011-06-10 17:17
Abusive administrators and unappreciative leadership have a detrimental effect on morale and are a deterrent to entering the medical profession.
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# Former Director x many yrsR Adams 2011-07-09 10:18
Dr Silverman is spot on. Very well written article. The point often missed is that doctors and businessmen really don't think alike. Doctors tend to focus on what is fair or reasonable and complain when it's not. Businessmen are simply focussed on what they are measured by - results. Despite impressions to the contrary, a decision to out a group is rarely personnal and nearly always a performance issue. It's fair to point out that if the CEO underperforms, he is out of a job, whereas you are still a doctor.
Finding out early (and personally) what makes the CEO tick and what his problem list consists of is a key administrative skill your group leader must have, and if he doesn't you need a new one. This has nothing to do with the quality of your groups' medical skills. Working creatively to produce win-win solutions for both the hospital and your group is what gains the respect of your administrators and in turn is what maintains your contract.
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# Motivation** 2011-07-26 17:59
The motivation to complete medical school comes from a desire to help the patient and make a positive impact. De-motivation comes from doctors and administrators who are negative, unethical, or who will sacrifice ultimate concern for the patient for profits. There is no excuse for doctors to lie to or mislead students. There is no excuse for doctors to lie to or intentionally mislead patients in a study. Perhaps non-compliant patients are really the ones who smartened up and realized the doctors saw them as experiments and wanted to use them for a profit or their own purposes. Of course there are trust issues. Abusive administrators who seem more concerned about maintaining power than what is best are a liability that will have a long term negative effect on the bottom line because of the negative costs from their egotistical attitudes. They are a deterrent to entering the medical profession because they detract from its true mission and this is repulsive to students who are drawn by the ideals of medicine.
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